<!DOCTYPE html>
<html>
<title>Register</title>
<style>
    input {
        display: block;
        margin-bottom: 15px;
    }
    
    input[type="submit"] {
        padding: 6px 4px;
    }
    
    label {
        display: inline-block;
        float: left;
        width: 100px;
    }
    
</style>
<body>
	<form method="post" action="https://secure.axes-payments.com/cgi-bin/credit/link-point.cgi" target="_blank">
		<label>Site Code*</label>
		<input type="text" name="site_code" value="A019000063"> 
		<label>Amount*</label>
		<input type="text" name="amount" value="190.80"> 
		<label>Currency*</label>
		<input type="text" name="currency" value="usd">
		<label>User ID*</label>
		<input type="text" name="user_id" value="1"> 
		<label>Telephone</label>
		<input type="text" name="telephone_no" value="906679888"> 
		<label>Email</label>
		<input type="text" name="email" value="tucq88@gmail.com"> 
		<label>Order Code</label>
		<input type="text" name="order_code" value="<?php echo rand(1, 10000)?>"> 
		<label>Optional</label>
		<input type="text" name="optional" value="optional"> 
		<label>Success URL</label>
		<input type="text" name="success_url" value="success"> 
		<label>Failure URL</label>
		<input type="text" name="failure_url" value="failure"> 
		<label>Language</label>
		<input type="text" name="lang" value="en">
		<!-- <label>Request</label>
		<input type="text" name="request" value="auth"> --> 
		<input type="submit" value="subscription">
	</form>
</body>
</html>